Successful lung transplantation in the presence of pre-existing donor-specific cytotoxic HLA Class II antibodies

Pre-existing HLA antibodies are a well-established causal factor for rejection and graft dysfunction after solid-organ transplantation. In lung transplant recipients, the significance of HLA antibodies has not been fully established. Although rare, several cases of hyperacute rejection of the lung allograft due to pre-existing donor-specific HLA antibodies have been described. In contrast, we describe successful lung transplantation in a patient with pre-existing donor-specific HLA antibodies. Routine screening prior to lung transplantation revealed cytotoxic HLA Class II antibodies, directed against the alpha chain of HLA-DQ, induced by a previous liver transplant. Due to clinical deterioration, it was decided to accept a lung offer without virtual crossmatching for DQ compatibility. Cytotoxic antibodies against the lung donor were confirmed retrospectively, resulting in strong positive B-cell crossmatches. Interestingly, the patient showed no clinical or histologic signs of rejection. This case demonstrates that the presence of high levels of pre-existing donor-specific HLA antibodies does not necessarily lead to rejection and graft failure. Although screening for antibodies prior to transplantation remains crucial, this study shows that we are thus far not able to predict the effect of pre-existing HLA Class II antibodies on allograft survival in individual patients.